NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name

Transcription

1 NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone # Fax # Address Father s Full Name DOB Address Education Occupation Home Phone # Work Phone # Mother s Full Name Address Education Occupation Home Phone # Work Phone# Best number to contact parent is Party bringing child to appointment Siblings: Name: Age Health Problems

2 Health History Patient Date Reason for visit: Date symptoms first occurred Are symptoms continuous? Yes No If NO please list dates and details: Please list any blood work done or tests previously performed: Please have the following Information below available at your next appointment Current Medications Dosage Time Given Past Medication tired for present condition: Was Child hospitalized for above condition?: PAST MEDICAL HISTORY Is this child yours by: Birth Adoption: Step child Other PREGNANCY Mother s totally # of pregnancies Number of Living Children Mother s total # of Abortions Number of Miscarriages Pregnancy with this patient was Normal? Yes No If NO please explain Were any drugs or medications used during the Pregnancy? Yes No If YES please list BIRTH HISTORY Birth Wt Birth Length APGAR SCORES Length of Pregnancy Type of delivery: Vaginal C-Section Planned Emergency Did child have any complications during or immediately following birth: Yes No If YES Please explain Developmental Milestones

3 Age child rolled over Spoke first words Sat up spoke in sentences Crawled Potty trained Cruised Walked Is your child s social development normal: Yes No If NO please describe (introverted, extroverted, aggressive, etc.) Is your child s educational development normal? Yes No If NO please describe (Regular ed., Special ed. etc) Is your child physical development normal? Yes No If NO please describe (fine motor skills, walking, running, etc.) Medical History Medical Date of onset Anemia Hydrocephalus Arthritis Leukemia Asthma Meningitis Bleeding Disorders Migraines Cerebral Palsy Pneumonia Concussion Psychology history Congenital heart Abnormality Seizures Diabetes Skeletal Disorders Growth Abnormalities Other Hospitalizations/ Operations (with age) Family Members Health History Does anyone in your family have or have a history of Cardiac Disease Strokes Depression Seizures Drug Addiction Seizures with fever Eye Disease Slow Development Migraines Schizophrenia Manic Depression Panic Attacks Muscle Disease Violent Behavior Nerve Disease Review of Systems General YES COMMENTS

4 Fatigue Joint pain/ muscle pain Weight gain Weight Loss Change in appetite Night Sweats Fever/ Chills Eyes Do you wear glasses? Eye Problems Lazy Eye Ears/ Nose/ Throat and Mouth Earache/ drainage Sore Throat Teeth/ gum problems Hearing Loss Nasal Allergies Nose bleeds Respiratory Cough Shortness of breath Wheezing Cardiovascular Chest pain Congenital heart defect Irregular heart beat Gastrointestinal Difficulty in swallowing Vomiting Nausea Food Intolerance Diarrhea Constipation Abdominal pain Genital-Urinary Problems with urination Bedwetting

5 Painful urination Kidney Stones Recurrent bladder or Urinary Tract Infections Irregular period Skin Change in hair and nails Birthmarks Rashes Lumps or growths Change in skin color Endocrine Hormone problems Temperature intolerance Diabetes Thyroid disease Hematology/ Lymphatic Anemia Bleeding or bruising tendencies Blood clotting disorder Past transfusions Allergic/ Immunologic Hay fever Hives Itching Allergies or drug reactions Food allergies Psychiatric Anxiety Depression Memory loss Short attention span Confusion Parent/ Guardian Signature